Healthcare Provider Details

I. General information

NPI: 1598158784
Provider Name (Legal Business Name): LISA NIEMCZYK GLOGOWSKI C.R.N.A
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2015
Last Update Date: 02/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8990 SPRINGBROOK DR NW STE 250
COON RAPIDS MN
55433
US

IV. Provider business mailing address

10600 250TH ST E
LAKEVILLE MN
55044-6409
US

V. Phone/Fax

Practice location:
  • Phone: 763-260-8808
  • Fax:
Mailing address:
  • Phone: 651-492-4882
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1772
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: